Basic Information
| Provider Information | |||||||||
| NPI: | 1538658380 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO TREATMENT OF MISSOURI, LP | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEW SEASON ST. CHARLES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MAITLAND CENTER PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2027 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633011047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363217600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2018 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4073517080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO TREATMENT OF MISSOURI, LP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.